Bryson City Tales — Lessons in Daily Practice (Part 2)

This is from the fourteenth chapter from my best-selling book, Bryson City Tales. I hope that you’ll enjoy going back to Bryson City with me each week, and that if you do, you’ll be sure to invite your friends and family to join us.

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LESSONS IN DAILY PRACTICE (PART 2)

My next patient that day was Leonard, a ninety-eight-year-old man who came to the office for, of all things, a premarital exam. Too embarrassed to tell the staff that it was a premarital exam— for reasons that became fabulously famous during the subsequent months—he simply scheduled a routine heart exam.

In those days doctors were still doing premarital exams and the state required a blood test for syphilis. (We had only four or five sexually transmitted diseases to be concerned about then; these days it’s approaching fifty.) Anyway, Leonard’s previous three wives had all succumbed to cancer. His impotence problems with wife number three had been “healed” by Mitch’s pre- scription of topical nitroglycerin.

During his exam, this brittle elder, who suffered from labile congestive heart failure secondary to several heart attacks, as well as very unpredictable chest pain secondary to a severe case of coronary artery disease, confided to me that he was marrying a young barmaid.

“Why?” I queried.

“Because,” he replied, smiling, “I wanted to marry someone who would outlive me!”

“Are you gonna consummate this thing?” I asked.

“Of course!” he exclaimed. “But not until we’re married!”

“But,” I protested, “you must be very, very careful. Too strenuous of a honeymoon could mean a heart attack or even death!” He looked me straight in the eye and said, “Well, Doc, if she dies, she dies!”

I think I must have looked, for a moment, utterly bewildered. Then he smiled and began to laugh. I realized I’d been snookered. He confessed that he was actually marrying a “proper” woman, although she was twenty years his junior. I began to chuckle, both at myself and then with him. We both began to laugh and laugh until we had tears running down our faces. Helen barged in to shush us up. We continued to do some shushed-up giggling.

One of the many truisms of medicine is that the doctor-patient relationship is foundational to the healing process. I have found that this involves each party learning how to teach the other. Many of the pearls of wisdom and the practical tips I’ve gleaned over two decades were discovered by my patients and taught to me. Some have subsequently been evaluated scientifically—while others remain anecdotal observations only.

 

Delores Smith was one of those patients who taught me. This elderly woman suffered from recurrent nosebleeds that occasionally required a trip to the office for an anterior nasal pack or a cauterization. I had tried all of our standard treat- ments, but topical steroids, nasal saline, topical petroleum jelly, topical Neosporin, and room humidification didn’t help at all. I was befuddled. Finally I decided to try a new trick that I had picked up at a medical conference.

“Delores, here’s a prescription for an antibiotic ointment. You just take a dab and rub it on the inside of each nostril—once in the morning and once in the evening. Then you kind of give your nose a pinch to spread the ointment a bit. If you use this every day, and keep using a humidifier, I think this’ll do the trick.”

I didn’t see her for many months, and I was sure my therapy was the distinct reason she wasn’t coming in with any more nose-bleeds. She next appeared in the office for her annual exam that spring. During the exam I commented, “Delores, I see from your chart that you’ve not been in for any more nosebleeds. I guess the ointment I prescribed must have worked for you.”

“Well . . . ,” she started, then blushed, looking away. “A prescription ointment did do the trick.”

There was an uncomfortable pause in the conversation. “Was it the ointment I prescribed?” I asked.

Another pause—her eyes still turned away from mine. She shook her head no.

“Whose then?” I asked.

“Well, Doctor, it was a prescription from Canada.”

Trying not to act too defensive, I inquired, “What type of prescription?” Actually, I was a bit curious. A family doctor can never have too many tools in his black bag. Maybe I would learn about a new one today.

“Fortunately for me, Dr. Larimore, my sister Dianna, who lives in Nova Scotia, inherited the same family predisposition to these types of nosebleeds. Her general practitioner, an ancient man, explained to her that the rosiness of her ruddy Irish cheeks had just migrated into her nostrils. He explained that this seemed to happen in only the most sensitive and exquisite of the grand dames. My sister found this medical assessment charming—especially when this gentleman explained that even Queen Victoria herself suffered this malady.”

What a cunning old codger, I thought to myself of my Canadian colleague. A master of the bedside technique!

She continued, “He explained to her that as a woman matures . . .”

Matures! What a great expression! My interest in and admiration for this fellow was increasing by the moment.

“. . . the skin can thin a bit—become a tad more fragile, dainty, and delicate. This can be true inside the nostril as well as among other parts.”

“So what did he recommend?” I wasn’t even remotely prepared for the answer.

“Premarin cream,” Delores stated matter-of-factly.

I couldn’t contain my surprise. “Premarin vaginal cream?” This common preparation of topical estrogen was often prescribed to women after menopause to thicken the walls of the vagina if vaginal dryness or pain during intercourse was a problem.

Delores looked at me as though I was daft. “But of course! He said that the lining of a woman’s private parts and the lining of her nostrils contained the same type of skin. Didn’t you know that?”

“Well,” I stammered, “of course I knew that. I’ve just never heard of using this cream in the nose.”

“He told my sister that most doctors had never bothered to think this through, but that since the skin of both areas is the same, then the same treatment could be used for both. He told her he had been prescribing it for years.”

“Well, quite frankly, Delores, it makes a bit of sense, I must admit. How did he say to use it?”

Her smile radiated as she became the professor, I the pupil. She was fairly gloating in the experience. “This is what he told my sister to do, and it’s what I did too. I applied a BB-sized drop of the Premarin cream to the inside of each nostril with a Q-tip—twice a day for thirty days, then daily for thirty days, then three times a week for another month, and then one or two times per week until the weather began to get a bit warmer.”

“How long did it take to work?”

“I had no more nosebleeds after using the cream for just a few weeks.”

“Mind if I take a look?”

“Of course not.”

The inside of her nostrils looked nice and pink. None of the unsightly little spider veins I had seen last fall.

“Delores, your nasal mucosae look almost as beautiful as you do.”

She blushed. I can pick up a thing or two, I thought—even across international borders!

“Thanks for the teaching,” I said.

She looked at me, cocking her head as though in disbelief. I could almost read her mind: A doctor—thanking me for teaching him? 

“Thank you,” Delores answered, “for being such an attentive pupil.”

She smiled.

So did I.

UPDATE: A September 2016 study, published in JAMA showed that patients received twice-daily nose sprays for 12 weeks with nasal saline spray (salt water) did just as well as those who used a topical estrogen (estriol 0.1%) for hereditary hemorrhagic telangiectasia (HHT; also known as Osler-Weber-Rendu disease). 

(TO BE CONTINUED NEXT FRIDAY)

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© Copyright Walter L. Larimore, M.D. 2016. This blog provides a wide variety of general health information only and is not intended to be a substitute for professional medical advice, diagnosis, or treatment from your regular physician. If you are concerned about your health, take what you learn from this blog and meet with your personal doctor to discuss your concerns.